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Dental Health History Form What concerns do you have about your oral health or smile?___________________________________ What are your goals in coming to our practice today?_________________________________________ What is important to you in a dentist or dental practice?_______________________________________ What has been your experience with dentists in the past?______________________________________ Date of last xrays:_______________________ Date of last Exam:______________________________ Date of last dental cleaning or periodontal maintenance appointment:____________________________ Former Dentist:_____________________________________ Phone:____________________________ Address:_____________________________________________________________________________ If you left your previous dentist, what are the reasons?_________________________________________ Have you had problems with prior dental treatments? Yes No If yes, please explain____________________________________________________________________ Are you experiencing any dental pain now? Yes No If yes, please explain____________________________________________________________________ Have you ever been pre-medicated for dental treatment? Yes No If yes, please explain____________________________________________________________________ Have you been anxious about dental treatment? Yes No If yes, would you be comfortable sharing why?________________________________________________ Would you like to discuss this concern with Dr. Trester to learn about your relaxation options? Yes No Do you have or had any of the following concerns with your oral health or smile? Jaw Joint Pain Unhappy with appearance of teeth Clenching/grinding teeth Tooth/gum sensitivity hot/cold Spaces between teeth Food gets caught in between teeth Discolored teeth Crowded/crooked teeth Uncomfortable bite Difficulty chewing/chewing on one side Old fillings/crowns Swelling or unusual lumps Speech problems popping/clicking when opening/chewing Tooth shape/size Too much gums show when smiling Have you ever had orthodontic treatment (braces)? Yes No Missing teeth Overbite Underbite Bad breath/bad taste Loose tooth/teeth Dry mouth Bleeding gums Other______________ When___________________________ Have you ever had periodontal (gums tissue) treatment, such as deep cleanings, root planings, or periodontal surgery? Yes No When ________________Dentist_________________________ Are you interested in learning more about the following? Periodontal disease prevention Tooth colored fillings/crowns At home oral hygiene care Orthodontic treatment Oral hygiene care for elderly Invisalign/Clear Braces Oral hygiene care for children Sleep apnea appliance Dental Implants Veneers Teeth Whitening Snoring appliance “If there is any additional information that the Doctor may need to know to treat me safely and effectively, I will personally discuss it with the Doctor. I have reviewed all the information on this entire questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the dental staff to help determine the appropriate and healthful dental treatment. At each visit a treatment plan will be presented and explained to me before any treatment is begun. I give the Doctor my consent to perform any needed dental treatment. I authorize the Doctor to release all information necessary to secure dental benefits from my dental insurance company. I authorize my insurance company to pay the Doctor all insurance benefits for services rendered. I understand that I am fully responsible for ALL services whether covered or not covered or denied by my insurance company.” Patient signature ___________________________________________ Date_____________________________ (Parent or guardian if patient is a minor)
